Anesthesia

Report
- Anesthesia and Analgesia
after Total knee replacement« State of the Art »
Patrick NARCHI, MD
Centre Clinical
16800- Soyaux
France
TKR: surgical characteristics
• Surgical risk
moderate
• Surgical duration
60 – 240 minutes !!!
• Bleeding
– intraoperative
– Postoperative
+
+++
• Postoperative pain
related to flessum
Anesthetic technique ?
• GA ? Why not?
– Preoperative epidural or femoral catheter
• Spinal anesthesia
– Combined Spinal-epidural
– Femoral catheter
• Nerve blocks
– Psoas block (catheter) + sciatic block
– Intraoperative sedation or TIVA
Prevention of Spinal anesthesiainduced hypotension in the elderly
Buggy D, A&A 1997
Cristalloids
500 ml
Colloid
500 ml
control
P=
hypotension
62
39
46
0.1
% vasopressors
45
29
39
0.4
Ephedrine (mg)
6.4
5.9
6.8
0.4
Nausea/vomiting
7
14
7
0.7
Mortality / Morbidity:
RA – GA : No difference
Operating time
Mortality
Cardiovascular morbidity
DVT / Pulmonary embolism
Intra-operative blood loss
Bleeding after major orthopedic surgery
GA = Reg Anesth
regional anesthesia
% major bleeding
5
2.3
2.1
4
3
2
1
0
Major bleeding
other anesthesia
TKR: tourniquet or not ?
• Any effect on bleeding?
–
–
–
–
Hersekli MA,
Schuh A,
Tetro AM,
Jorn LP,
NO
Int Orthop. 2004
Zentralbl Chir. 2003
Can J Surg. 2001
Acta Orthop Scand. 1999
• Any effect on venous thrombosis?
– Wauke K, Arch Orthop Trauma Surg. 2002
– Harvey EJ, J Arthroplasty. 1997
Yes
No
The postoperative challenge !
Why Regional Analgesia ?
• Superior to iv PCA (opioids)
• Excellent “dynamic analgesia”… 72h
• Avoids opioid-side effects
– nausea-vomiting +++
– sedation
•
•
•
•
•
•
Epidural analgesia ?
Psoas, femoral block, iliofascial block ?
Is an obturator nerve block really useful ?
Sciatic block ?
Single shot or catheter?
Infiltration ?
Peripheral nerve catheters > Epidural
• Efficacy:
PNB  Epid
• Side effects:
PNB < Epid
• Major Complications: PNB < Epid
* Epidural abcess
* Epidural hematoma
Watson M.W, RAPM 2
Spinal anesthesia
Sciatic 15 ml levoB
Psoas Catheter:
- bolus 25 ml levoB
- perfusion
* placebo
* L-Bupi
PCA iv (morphine)
Is the catheter really necessary ?
Prolonged analgesia
similar 3 months outcome
Functional Outcome
Resting and Peak VAS Pain
Systemic analgesic requirement
Sciatic nerve block for total-knee replacement:
is it really necessary in all patients ?
Levesque S, Delbos A, RAPM 2005
200 TKR patients
N= 25 (12.5%) needed a single sciatic block in PACU
Predictive risk factors of pain
1- Flessum
2- important preoperative pain
Pham Dang C, RAPM 2005
• PCA Morphine (mg)
23 mg vs 4 mg *
• Vomiting
43% vs 14% *
What about 0,3mg spinal morphine ?
Effective
Adverse effects: PONV– Pruritus
Total knee replacement
is the femoral catheter enough ?
- (D0- D1): pain anterior & posterior !
The catheter is not enough
- Sciatic block (Allen, Weber, Mansour)
- morphine: iv PCA, spinal, s/cut …
- (D2- D4): physiotherapy ….
- the femoral catheter is sufficient
Total knee replacment …
Regional analgesia >> PCA morphine
•
•
•
•
Quality of analgesia
Quality of early physiotherapy: KINETEC
Discharge criteria: Knee Flexion at 90
Duration of physiotherapy +++
• PCA
50 days
• Epidural
37 days
• PNB
40 days
Femoral Nerve Block Improves Analgesia
Outcomes after Total Knee Arthroplasty
A Meta-analysis of Randomized Controlled Trials
(JE Paul,
Anesthesiology 2010)
• Single shot FNB >> iv PCA till 48h
• Compared to a single shot FNB:
– Addition of Sciatic block
no benefit
– Femoral catheter
no benefit
Functional Outcome after TKR:
Any benefit from Regional analgesia
?
D0
D3
1w
2-3 months
Carli 2010
Kadic 2009
1year
Colwell 19
Munin 199
Total knee replacement
Regional Analgesia > PCA morphine
But …
The final functional result of the
operated knee is not related to any
analgesia technique or drug …
Colwell 1992, Munin JAMA 1998
Infiltration + intraarticular analgesia vs
femoral nerve catheter after TKR
Toftdahl K, Acta Orthopaedica 2007
• 80 TKR, spinal anesthesia
• Femoral catheter
• Infiltr at the end of surg + Intraarticular catheter 2 inj
femoral Infilt + artic
Worst pain score during
physical therapy D1
Oxycodone (mg) D1
Able to hold quadriceps D1
statistics
5
3
*
100
50%
83
80%
**
***
INFILTRATION :
EFFECTIVE
EVIDENCE
INFILTRATION VS OPIODS
Better analgesia
Less consumption of opiods
Andersen LO, Acta Anaesth Scand 2010
• 150ml Ropi 0,2%
• Capsule, muscles, S/cut
• Subcutan Catheter
Infiltration
- Bolus effective
- Catheter: no efficacy
Total Knee Replacement
The Past ... The Present ... And the Future !
• Anesthesia GA = Spinal = Blocks
• Postoperative Regional Analgesia
– Femoral block is the standard today
– Femoral catheter … longer analgesia
– Obturator block … weak interest
– Sciatic block … for the first 24h
– LIA … promising but requires larger surveys
EARLIEST FUNCTIONAL OUTCOME
IMPORTANCE OF ANALGESIA TECHNIQUE
EVIDENCE
Discharge Critera :
adequate analgesia
independence from iv analgesics
ambulation of at least 30 meters
80
60
Day 5
Discharge
1 month
3 month
A
B
C
60
80
90
125
80
90
95
125
85
90
105
130
40
25 h
20
71 h
0
1
2
Ilfeld BM Anesthesiology 2008
Knee flexion depends on
analgesia technique
Continuous blockade of the
lumbar plexus after knee
surgery
Dahl JB, Anaesthesia 1988
• TKR under GA & femoral catheter
Urgent urinary drainage : 20%
!!!
Bladder management after total joint
arthroplasty
Knight RM, J Arthroplasty
1996
174 patients
ECBU (+)
Foley
8%
intermittent
12%
p=
NS
Resondage > J3
16%
25%
**
Economie - 150 minutes de nursing time
- 3000 $ par patient
FEMORAL NERVE BLOCK
IDEAL TECHNIQUE
EVIDENCE
EFFECTIVE
LESS SIDE EFFECTS
FAST FUNCTIONNAL RECUPERATION

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